Healthcare Provider Details

I. General information

NPI: 1790049211
Provider Name (Legal Business Name): SARAH BUMGARDNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2012
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S LIMESTONE
LEXINGTON KY
40536-1927
US

IV. Provider business mailing address

128 SOUTHLAND DR
LEXINGTON KY
40503-1927
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5603
  • Fax: 859-323-3704
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberPA1622
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1622
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA1622
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1622
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: